Healthcare Provider Details

I. General information

NPI: 1255354270
Provider Name (Legal Business Name): OUT REACH MOBILE IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 CANYON RD E STE 8
PUYALLUP WA
98373-4200
US

IV. Provider business mailing address

11012 CANYON RD E STE 8
PUYALLUP WA
98373-4200
US

V. Phone/Fax

Practice location:
  • Phone: 253-921-6613
  • Fax: 253-435-1933
Mailing address:
  • Phone: 253-921-6613
  • Fax: 253-435-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number19683
License Number StateWA

VIII. Authorized Official

Name: THERESA M TREBILCOCK
Title or Position: OWNER
Credential: RDMS, RDCS
Phone: 253-921-6613